Advantage AVF-1 Schedule of Benefits

Restorative Services (Fillings) Schedule

Diagnostic X-Rays and Tests Preventive Care Restorative Services (Fillings) Other Restorative Services Crowns and Bridges

Endodontics Periodontics (Gum Treatment) Prosthetics (Dentures) Extractions & Oral Surgery Orthodontics (Adults or Children) Miscellaneous Services

Limitations and Exclusions

ADA CODE		Procedure		Member Pays
		MINOR RESTORATIVE SERVICES
D2140		AMALGAM-1 SURFACE, PRIMARY OR PERMANENT		$19
D2150		AMALGAM-2 SURFACES, PRIMARY OR PERMANENT		$25
D2160		AMALGAM-3 SURFACES, PRIMARY OR PERMANENT		$31
D2161		AMALGAM-4+ SURFACES, PRIMARY OR PERMANENT		$37
D2330		RESIN-1 SURFACE ANTERIOR		$21
D2331		RESIN-2 SURFACES ANTERIOR		$27
D2332		RESIN-3 SURFACES ANTERIOR		$33
D2335		RESIN-4+ SURFACES OR INCISAL ANGLE		$40
D2390		RESIN-BASED COMPOSITE CROWN, ANTERIOR		$44
D2391		RESIN-1 SURFACE POSTERIOR		$25
D2392		RESIN-2 SURFACES POSTERIOR		$33
D2394		RESIN-3 SURFACES POSTERIOR		$41
D2394		RESIN-4+ SURFACES POSTERIOR		$49
		MAJOR RESTORATIVE SERVICES
		Inlay and Onlay Restorations (Limited to 1 per tooth every 5 years)
D2510		INLAY-METALLIC-1 SURFACE		$272
D2520		INLAY-METALLIC-2 SURFACES		$309
D2530		INLAY-METALLIC-3+ SURFACES		$356
D2542		ONLAY-METALLIC-2 SURFACES		$349
D2543		ONLAY-METALLIC-3 SURFACES		$365
D2544		ONLAY-METALLIC-4+ SURFACES		$380
D2610		INLAY-PORCELAIN/CERAMIC-1 SURFACE		$320
D2620		INLAY-PORCELAIN/CERAMIC-2 SURFACES		$338
D2630		INLAY-PORCELAIN/CERAMIC-3+ SURFACES		$360
D2642		ONLAY-PORCELAIN/CERAMIC-2 SURFACES		$350
D2643		ONLAY-PORCELAIN/CERAMIC-3 SURFACES		$377
D2644		ONLAY-PORCELAIN/CERAMIC-4+ SURFACES		$400
D2650		INLAY-COMPOSITE/RESIN-1 SURFACE LAB PROCESS		$210
D2651		INLAY-COMPOSITE/RESIN-2 SURFACES LAB PROCESS		$251
D2652		INLAY-COMPOSITE/RESIN-3+ SURFACES LAB PROCESS		$263
D2662		ONLAY-COMPOSITE/RESIN-2 SURFACES		$229
D2663		ONLAY-COMPOSITE/RESIN-3 SURFACES		$269
D2664		ONLAY-COMPOSITE/RESIN-4+ SURFACES		$288

Note:
All procedures listed might not be performed by the Participating General Dentist you select. The co-payments shown apply to those Participating General Dentists who do perform those services. Therefore, you are encouraged to discuss the availability of the scheduled services with your Participating General Dentist. Procedures not listed on this schedule of benefits, that are performed by the Participating General Dentist, will be charged at that Participating General Dentist's usual and customary fee less 20%.

Specialist Services
Should you need a specialist (i.e. Endodontist, Oral Surgeon, Orthodontist, Periodontist, Prosthodontist, Pediatric Dentist), you may be referred by your Participating General Dentist. Co-payment percentage amounts are applicable when treatment is performed by a Participating Specialist. Procedures not listed on this schedule of benefits, that are performed by a Participating Specialist, will be charged at that Participating Specialist's usual and customary fee less 20%.